Utilization Review Registered Nurse, Case Management

Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors.

What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in.

Description:

The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated salary range for this position is $35.51 - $46.16 / hr depending on experience.

Qualifications:

Degrees:

• Associates.

Licenses & Certifications:

• MCG Care Guidelines Specialist.
• Registered Nurse.

Additional Qualifications:

• RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN.
• however, they are required to complete the BSN within 3 years of job entry date.
• MCG Specialist Certification ISC/HRC required within 12 months of job entry date.
• 3 years of Nursing experience preferred.
• Excellent written, interpersonal communication and negotiation skills.
• Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently.
• Strong analytical, data management and computer skills.
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
• Current working knowledge of payer and managed care reimbursement preferred.
• Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.
• Knowledgeable in local, state, and federal legislation and regulations.
• Ability to tolerate high volume production standards.

Minimum Required Experience:

3 Years of Nursing experience required

EOE, including disability/vets